0402-317 (RPL)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
I—CYU
2?Signature
C'53 C61 D35 � 1Z13IXV
o Z / / D e 4 X� of Contractor ''O
CD _
r— ~0 OWNER -BUILDER DECLARATION
HW r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z_ ( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, business & rrofessionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
C0 () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
O�
aQ WORKER'S COMPENSATION DECLARATION
o Cc I hereby affirm under penalty of perjury one of the following declarations:
Lo FQ- O () 1 have and will maintain a certificate of consent to self -insure for workers'
.x W Y= compensation, as provided for by Section 3700 of the Labor Code, for the
O Q performance of the work for which this permit is issued.
m Q C) ( ) I have and will maintain workers' compensation insurance, as required by
O 0 Q Section 3700 of the Labor Code, for the performance of the work for which this
d F- permit is issued. My workers' compensation insurance carrier & policy no. are:
ob Carrier WIDA.Tl? F�iJ`ND Policy No. 1683412-02
a.
J (This. section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with -t ose provisions. K
/ /Date- 4 Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $.100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspecti n purposes.
� Kerry i
f ✓Signature (Owner/Agent) �`�' ..fir �* �` ' , ^' Date-� �/!)Y
BUILDING PERMIT PERMIT#
DATE ^ VALUAT.ION�, 4.t.9
LOT S {-017 TRACT
r, 1 �� ew).w
JOB SITE
ADDRESS
APN
MW VIA `l.KIWA.CINA
M
OWNER..
CONTRACTOR/DESIGNER/EN (NEER
xt '1 i ,A3 3 i t
BUBBLE 3P1t WGS
SO -565 i�.�',MMA,CNA
7) 509 SAIN OORGOINIO
i./:ri1rM)T.A. CA 42233
RANCHO 14�4i AGE CA 92270
(760)341.2336 CBL t 5486
I ISF OF PERMIT
POOL. AND/OR er`A
POOLAPA. A'r,..ireRVIV- AAIMEitS SP AIJ, fir, IN PLP.CP. AT PRE -PLASTER.
WSPECTIOW, 'eQUIPMEt4T E'niCI oitinzxoT I14CI.,UDEiO
POOL.o'1?J.D/(7TZ SPA 2€400.00 L5
D COST 01r CONY.s.dKITC110L\
.��e'/iOri.Eis7
rA3C.yr7�.11�/J':9,.S:a:
�d'�'f1Y3.i..R 1i5CL7'. �L1.1.5R.1.L'rl.tld-�+.F.
PWI CURCK FFE 101-M0-439-3)8 8172,15
CONSTRUCTION ME 1G1-000-418-rit`)'Ji $i6i.fU
.&IRCN..041CAL F£% — P001, 101.000.1I21•000 S24A
ELECTRICAL- FSPE • POOL 101-1700.420.400 $43.00
PLUF1l.11*40 IEE -• Po4L, 101.00C!-19>000 $27,00
COMRITCT101 f AND I''`:" CF �
3 S
D a �I iw PR&PAID IS=
$0.00
PERMIT FRES D17E NOW
��� 2 71004
CITY OF LA QUINTA
FINANCE DEPT. -
I 'v
RECEIPT
DA , f
BY
DAT vyJ SPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
_
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
S Connection
Gas Piping
Pool Cover
Encapsulation
,T
Ga est
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
'Temp. Power Pole
Underground Conduit
Rough Wiring
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)